Basic Information
| Provider Information | |||||||||
| NPI: | 1114296720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AYRES | ||||||||
| FirstName: | MARCY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3949 SOUTH 6TH ST. | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976034746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5418821670 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 CHILOQUIN BLVD. | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5417833273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2011 | ||||||||
| LastUpdateDate: | 10/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1016943 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.